2.0 Analysis 2.1 Access to the Loading Ramp The former owner and his uncle were not passengers and did not take part in the loading and stowage of the cement mixer on the CAMILLE MARCOUX. It appears that the instructions provided in the user guide for the Baie-Comeau ferry wharf were not followed, in that the former owner and his uncle were allowed to move about freely on the loading ramp. The former owner and his uncle left the parking deck and proceeded toward the loading ramp just as the tow truck was about to do the same. The former owner was struck by the tow truck when he was on the loading ramp apron, with his back to the tow truck. 2.2 Vehicle Traffic In the interests of safety, vehicles are driven forward when entering and exiting the parking deck so that less visual effort and concentration are required of the drivers of cars and heavy trucks. In this occurrence, because of the limited space at the front of the parking deck, when the tow truck driver had finished loading the cement mixer, no one asked him to turn around and drive to the exit in a forward gear. It would have been easier for the driver to see the pedestrians if he had been driving forward toward the loading ramp. 2.3 Assistance for Drivers of Heavy Trucks Owing to their dimensions, heavy trucks have a limited field of view, which includes more blind spots than does that of a car. Consequently, the help of a second signaller, positioned at the rear of the vehicle, would have enabled the tow truck driver to back up more safely, irrespective of the manoeuvre he had to make. However, at the time of the accident there was only one signaller, positioned at the front of the tow truck, to help the driver proceed to the exit. A second signaller at the rear of the tow truck would have seen the pedestrians. 2.4 Impact of Ferry Schedule on Safety Ferries transport a considerable number of passengers and vehicles and operate on tight schedules, which they must adhere to as closely as possible, especially in summer. The employees of ferries and terminals must endeavour to avoid delays because once a ferry is behind schedule it is difficult to get back on schedule. In this instance, loading the cement mixer with the tow truck slowed down operations. Two blasts of the whistle were sounded to remind the crew to finish loading as soon as possible. Although there was apparently no pressure on the crew to adhere strictly to the ferry's timetable, they could have interpreted the whistle blasts as the start of preparations for departure, and this could have added to their stress. The limited time available to the ferry before departure and the signal to the crew that they had about ten minutes to prepare for departure contributed to rushing the operations on the ferry; which added to the tow truck driver's stress as he was backing up. This situation led to the rapid movement of the tow truck toward the ferry exit. 2.5 Hazard Warning Although the loading ramp is equipped with traffic lights to control the movement of vehicles, these lights are not designed to alert pedestrians to hazards. Apart from safety measures such as the embarkation of pedestrians before vehicles, and ropes that demarcate the lane on the loading ramp reserved for pedestrians, the ferry wharf user guide does not provide for signs or visual or audible alarms to warn pedestrians of hazardous situations. Virtually the only means available to loading ramp attendants to warn passengers of danger is to call out to them. The attendant and other witnesses did just that before the accident, but to no avail. Moreover, the witnesses had little time to inform the victim because the tow truck was backing up quickly. 2.6 Backing-up Alarm Despite the many recommendations made by coroners since 1988 following similar accidents, the Quebec Highway Safety Code still does not require heavy trucks to be equipped with backing-up alarms. With regard to the former owner of the cement mixer, he was possibly upset from the animated discussion that he had had with the first mate and by the fact that he was seeing for the last time the vehicles that he had sold; this may have made him less aware of his surroundings when he walked onto the loading ramp. The fact that he only noticed the tow truck at the last moment suggests that the sound of the tow truck backing up may have been masked by other ambient noises produced by shipboard operations, and so did not attract his attention prior to the accident. Due to a growing interest in safety, some automobile manufacturers are currently working on the development of a detection system that would give drivers an audible and visual warning of a person or object behind their vehicle. The new technology should be on the market soon, and such a device could undoubtedly be installed on heavy trucks. In the meantime, some install an external backing-up alarm to help avoid such accidents. 2.7 Written Safety Management Instructions On adopting the International Safety Management Code on 04November 1993, the IMO invited companies to implement a safety management system at all levels of the company, on board ship and on shore. As the Code does not apply to ferries such as the CAMILLE MARCOUX-- which are not subject to the International Convention for the Safety of Life at Sea (SOLAS)-- the IMO can only promote the Code. Through safety management, written instructions can be developed to continuously improve the safety management skills of shore employees and shipboard personnel. Such instructions enable employees to use the latest procedures for the safe operation of roll-on/roll-off ferries. 3.0 Conclusions 3.1 Findings Pedestrians and vehicles used the same loading ramp to proceed to the parking deck. Two pedestrians were moving about freely on the loading ramp after the cement mixer had been loaded. The driver of the tow truck found himself in a stressful situation, as he had to manoeuvre his truck out of a confined space in the short time before the expected departure. There was only one signaller, positioned in front of the tow truck, to guide the driver to the exit while he was backing up in a confined space. The crew did not require the tow truck to turn around on the parking deck before proceeding to the loading ramp. The fact that the tow truck was backing up in a confined space without the help of a second signaller contributed to the accident. The victim and the tow truck driver did not look out for each other on the loading ramp apron. Repeated warnings made by the loading ramp attendant and others near the ramp failed to attract the attention of the former owner, who was moving toward the exit. Witnesses had little time to inform the victim because the tow truck was backing up quickly. Since 1988, coroners have made recommendations to the organizations concerned that they take action. Nothing has been put in place as yet to prevent this type of accident. Despite the many recommendations to the Socit de l'assurance automobile du Qubec (SAAQ) that backing-up alarms should be made mandatory equipment on heavy trucks, to date the Quebec Highway Safety Code contains no provisions to that effect. Only the loading ramp attendants have written instructions regarding their duties. 3.2 Causes The pedestrian was struck by the tow truck as he was walking on the loading ramp apron, with his back to the truck, because access was not closed to vehicles while pedestrians were walking on the loading ramp, and because a signaller was not positioned at the rear of the tow truck to guide the driver while he was backing up. The driver did not see the pedestrian walking on the apron, the tow truck was not equipped with an automatic backing-up alarm and the pedestrian did not look out for the tow truck as he left the vessel. 4.0 Safety Action 4.1 Action Taken 4.1.1 Coroner's Recommendations In the report on his investigation into this accident, the coroner made three recommendations: That the Socit des traversiers du Qubec (STQ) review its instructions regarding the unloading in reverse gear of any vehicle, to conform to articles 223 and 286 of the regulations governing industrial and commercial establishments made pursuant to the Act respecting occupational health and safety, and to regulation 9, chap. S-2.1 of the Quebec Pension Board, 1981, which states that when a motorized vehicle is backing up, a signaller must direct the driver if this movement of the vehicle can compromise the safety of a worker or of the driver. That the Socit de l'assurance automobile du Qubec (SAAQ) and the Ministre des transports du Qubec modify the Quebec Highway Safety Code such that it require vehicles over 5,500kg to be equipped with automatic backing-up horns. That the STQ, the Ministre des transports du Qubec and Transport Canada combine their efforts to build, on wharfs belonging to them, a separate pedestrian access that allows pedestrians to get to the upper deck of a ferry without having to walk on the parking deck. While the SAAQ finds the coroner's recommendation for automatic backing-up alarms to be a worthwhile goal, it considers that implementation would be problematic, as it would be difficult to justify the economic impact that the installation of a such device on more than 100,000 heavy trucks would have on the industry. The SAAQ recommends, rather, that a driver should make an initial check to ensure that the way is clear, and then be guided by a responsible person. 4.1.2 Pedestrian Boarding Ramp On 13 December 1996 the Board sent a Marine Safety Information Letter (MSI03/96) to the STQ. The purpose of the letter was to advise the STQ of deficiencies identified in the instructions for passenger embarkation and disembarkation. The STQ developed a plan for pedestrian boarding and, in 1997, made improvements to the passenger boarding facilities at the Matane and the Baie-Comeau terminals. These included a covered walkway and a completely separate boarding ramp, which now allow for safer boarding of pedestrians. 4.1.3 Audible Alarm Following this accident, the owner of the tow truck had a backing-up alarm installed on the vehicle.